This report is a result of an on-site complaint investigation conducted on March 6, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, BGI of Brandywine, Inc., was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiency was identified during this inspection and a plan of correction is due on May 1, 2008.
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Plan of Correction
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Observations
Based on a review of facility policy and procedure and client records, the facility failed to document vital signs as per the facility's written policy and procedure. The facility's policy and procedure stated vital signs would be checked and documented every six hours for clients in the detoxification level of care. Vital signs were not documented every six hours in eight of fourteen client records reviewed, #1, 4, 6, 8, 10, 11, 12 and 14.
Nursing notes indicated that the vital signs for client #1 were not checked during the overnight shift from 11/13/07 to 11/14/07. When client #1 was checked at 11:30 a.m. on 11/14/07, the client was unresponsive and had to be transported to the local emergency room.
Nursing notes indicated that the vital signs for client #11 were not checked from 7:00 p.m. on 10/17/07 until 6:00 a.m. on 10/18/07. There were no nursing notes documented in the client record during this time.
Vital signs were not documented during the evening/overnight shifts in six records, #4, 6, 8, 10, 12 and 14. Nursing notes only indicated that clients were in bed with no complaints and no vital signs were documented at 2:00 a.m.
Nursing notes indicated that the vital signs were not checked from 5:30 p.m. on 11/1/07 until the day shift on 11/2/07 in client record #4 .
Nursing notes indicated that the vital signs were not checked from 4:00 p.m. on 11/7/07 until the day shift 11/8/07 in client record #6.
Nursing notes indicated that the vital signs were not checked from 4:30 p.m. on 11/8/07 until the day shift on 11/9/07 in client record #8.
Nursing notes indicated that the vital signs were not checked from 1:45 p.m. on 10/3/07 until the day shift on 10/4/07 in client record #10.
Nursing notes indicated that the vital signs were not checked from 4:30 p.m. on 2/4/08 until the day shift 2/5/08 in client record #12.
Nursing notes indicated that the vital signs were not checked from 5:30 p.m. on 1/3/08 until the day shift on 1/4/08 in client record #14.
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Plan of Correction
Effective 4/17/08, Policy and practice has been changed to:
All patients in detox level of care will receive vitals q 4 hours until they are discharged or are transferred to another level of care (i.e. Rehab)
Also added a Vital Signs flow sheet for ease of documenting each patient's vital signs in the medical record.
Director of Nursing implemented above procedures as of 4/17/08 and will be responsible to assure practices are compliant via random chart audits and supervision. |